NHS policy seems populated by some remarkably persistent ideas that pop up every decade or so
Neil Gaiman’s novel American Gods is based on the premise that wherever a god has been believed in, she or he will survive long after the civilisation that worshipped them has disappeared.
Given the waves of immigration into the US, Gaiman imagines hundreds of deposed gods roaming the country in search of believers, or at least the consolation of a sacrifice every few centuries or so.
The NHS policy landscape may not quite have the sweep of the American plains, but it, too, seems populated by some remarkably persistent ideas that pop up every decade or so in search of believers.
Parallel to the coverage of the infection outbreak at Maidstone and Tunbridge Wells trust, it is perhaps not surprising that the twin gods of matrons and cleanliness emerge once again as the patron saints of patient safety.
We are promised a series of intensive environmental cleans. There is no doubt a dirty ward or department gives all the wrong messages. It suggests a lack of attention to the basics and a lack of care; it is also just unpleasant and depressing. And given that so many people believe that visible dirt equates to invisible pathogens, it is a concern that needs to be addressed.
However, the deep clean also diverts staff attention from the basic message that their own constant attention to hand hygiene will make the biggest single difference to the transmission and proliferation of infection.
The concept of the deep clean is regularly associated with the matron goddess. Deriving from the role of wife of the workhouse master, the matron was responsible for all the other nurses and domestic affairs of a public institution.
The title then died out after the Salmon report of 1967, but lived on in the vocabulary of the British public largely thanks to Hattie Jacques’ role in the Carry On films. Ms Jacques evoked an all-powerful but nurturing feminine presence and her matron has remained a constant in the public consciousness, resurrected regularly by politicians, particularly in times of crisis.
Alan Milburn established ward matrons in 2001 in response to concerns over cleanliness and in 2004 a target was introduced for employing community matrons for long-term conditions. This September, health secretary Alan Johnson told the Labour conference that ‘matrons are back’ to tackle infection, despite little evidence they had left since 2001.
The last time I remember polyclinics taking centre stage was the late 1980s when Margaret Thatcher sent teams of civil servants overseas to investigate alternative funding for the NHS. They came back from Germany with polyclinics, which at least diverted attention for a while from personal insurance as the answer.
However, the theme of finding community-based activities for hospital consultants is a recurring one. In his London review, Lord Darzi rightly identified a key principle as ‘localise where possible, centralise where necessary’. However in On/Off he also references US achievements in shifting outpatients to community settings. Given the lack of primary care in the US, much of this outpatient activity would have been seen by a GP in the UK anyway.
Meanwhile the many GP fundholding initiatives of inviting consultants to sit in GP surgeries and see a fraction of the patients they could have in a clinic should have been a lesson in both efficiency and inequality.
Value for money and quality will come from enhancing capacity and capability in primary care, so only those requiring secondary consultation should be referred to hospital, at which point outpatients is likely to remain the most efficient way of managing assessment. Technology should increasingly help medical staff to co-consult, or get rapid advice without requiring the patient to travel. Where consultants will have a role in community settings is in new models of care such as group consultations and multidisciplinary clinics.
And then there is the holy grail of NHS policy - local accountability. This is a theme revisited frequently, generally by those opposed to the dominant policy of the day and particularly popular with parties in opposition.
Underpinned by the myth of the democratic deficit it argues that (although the NHS is a national system, funded by a vote from Parliament out of national taxation) the NHS should not be accountable to the health secretary.
This is despite the fact that the health secretary is elected in a poll with a 60 per cent turnout while turnouts of 30 per cent are not uncommon in the polls that elect councillors. Councillors also have limited responsibility for fiscal policy and a vested interest in their own return to power within three years, so may be reluctant to change local services.
Interestingly, the same people concerned with local accountability are often those arguing against a postcode lottery, which would be even more inevitable without national political leadership of a national health service.
However, we are here operating in the realm of faith rather than rationality. The persistence of these ideas shows their continuing symbolic power. The common theme is another from mythology: the single silver bullet which with one shot slays the beast. The unfortunate reality is that managing change and developing policy for a complex system is rarely that simple and no one idea is likely to provide the whole answer.
Nevertheless, there are worrying signs world class commissioning is emerging as the latest incarnation of the One Truth. Having been alternately ignored and reorganised for years, commissioning is now expected to deliver the holy grail within the next 12 months.